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CHAPTER 2
Vulnerability-Stress Models
RICK E. INGRAM AND DAVID D. LUXTON

E
arly models of psychopathology (Brown & Harris, 1978, 1989). Such models
typically identified processes operat- suggest that severe enough negative events
ing during the course of the disorder could precipitate psychological disorders even
as reflecting the key determinants of the without reference to individual psychological
onset of psychopathology (e.g., irrational or biological characteristics. For example, the
beliefs; Ellis, 1962). Such models have led link between an adverse social environment
to important advances in understanding and the onset of depression has long been
important features of psychopathology. For recognized. The majority of research investi-
example, in the cognitive arena, schema gating possible links consistently finds a rela-
models initially focused almost exclusively tionship between the experience of stressful
on understanding cognitive variables func- life events and the onset of depression, with
tioning in the disordered state. This con- some data suggesting that approximately
ceptual approach, as well as the empirical 50% of individuals diagnosed with depression
research motivated by these models, has have experienced severe stress before onset
led to a number of significant insights into (Mazure, 1998). More recent perspectives
depression (Ingram, Miranda, & Segal, suggest the possibility that life stress may
1998), anxiety (e.g., McManus & Clark, engender a specific subtype of depression
2002), personality disorders (Beck, 1999), (Monroe & Hadjiyannakis, 2002).
and even problematic marital interactions Despite advancing understanding, the limi-
(Beck, 1989). Schema models thus represent tations of these approaches have become
a clear example of the power of such con- increasingly apparent. For instance, models that
structs as they apply to the description of place primary emphasis on stress as a key cause
psychopathology. of a disorder have difficulty dealing with data
Stress has also been recognized as an showing that even extreme stress is not linked
important contributor to the development and to psychopathology in all individuals (Monroe
course of psychopathology, so much so that a & Hadjiyannakis, 2002); after all, approxi-
variety of models have featured stress as a mately 50% of individuals do not show
primary determinant of disordered functioning evidence of a disorder such as depression

32
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Vulnerability-Stress Models 33

following significant life stress. Hence, although DEFINITIONS

data convincingly show that stress plays a role
in depression, they just as convincingly show Numerous discussions of vulnerability (e.g.,
that other factors also play a critical role. Ingram et al., 1998) and stress (e.g., Grant &
The fact that not all individuals who expe- McMahon, Chapter 1 of this volume) can be
rience significant stress develop a disorder has found in the literature. Detailed examination
led, in part, to the recognition that vulnerabil- of these ideas can be found in these sources.
ity processes are important components of psy- For purposes of context, in this chapter we
chopathology; such factors predispose some briefly note ideas about the individual con-
individuals to psychopathology when stress is structs that form diathesis-stress models. We
encountered. Notions about vulnerability have start with stress.
also begun to address questions about whether
variables operating within the disordered state
Stress
are antecedents of the state, or whether they
can reasonably be considered to be conse- Definitions of stress encompass a number of
quences of the state (e.g., Barnett & Gotlib, facets. In general, however, stress falls into a
1988). By definition, vulnerability to a disorder limited number of broad categories. One major
must serve as an antecedent of the disorder. category of stress is conceptualized as the
Although vulnerability ideas have been a cen- occurrence of significant life events that are
tral part of some of the earliest models of psy- interpreted by the person as undesirable
chopathology (e.g., Beck, 1967), the emphasis (Lazarus & Folkman, 1984; Luthar & Zigler,
on their essential nature in the onset of psy- 1991; Monroe & Peterman, 1988; Monroe
chopathology has seen a remarkable resur- & Simons, 1991). The accumulation of minor
gence (Segal & Ingram, 1994). events or hassles represents another kind of
Although vulnerability and stress can be stress (Dohrenwend & Shrout, 1985; Lazarus,
reasonably considered to be conceptually dis- 1990). Socioeconomic factors have also been
tinct constructs, separately, their power to implicated in stress, in that variables such as
describe key aspects of psychopathology is low maternal educational status or membership
limited. Thus, most modern models of psy- in an ethnic minority group may reflect stress-
chopathology explicitly combine vulnerability ful living circumstances (Luthar & Zigler).
and stress in their descriptions of the func- Although it is clear from these descrip-
tional processes leading to disorder. This tions that the definitions of stress are many,
chapter focuses on the interaction of vulnera- we can view stress in the context of this chap-
bility and stress as essential for understand ter as the life events (major or minor) that
ing the development of psychopathology. To disrupt those mechanisms that maintain the
serve as a background for exploring their stability of individuals’ physiology, emotion,
interactive role, we briefly provide definitions and cognition. Indeed, Selye’s (1963) classic
of vulnerability and stress and then briefly dis- description of stress notes that such events
cuss the origins of these constructs. We then represent a strain on the person’s adaptive
examine general principles that characterize capability that cause an interruption of the
most diathesis-stress models and, finally, person’s routine or habitual functioning.
explore different models of vulnerability-stress Stress thus reflects those factors that interfere
interactions. Finally, we comment on some with the system’s physiological and psycho-
issues that are pertinent to conceptualizations logical homeostasis.
of stress and conceptualizations of diatheses in Even though stress is frequently conceptu-
the context of the diathesis-stress relationship. alized as the occurrence of “externally”
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34 OVERVIEW AND FOUNDATIONS

ordained processes, two sets of factors suggest factors constituted genetic or biological
an important role for “internal” forces in the factors. In more recent years, the term has
occurrence of stress. First, although some been broadened to include psychological
stressful events may simply befall people, sev- factors, such as cognitive and interpersonal
eral researchers have persuasively argued, and variables, that make a person susceptible to
empirically demonstrated, that other events psychopathology (Monroe & Simons, 1991).
are the results of individuals’ own actions Intuitive ideas about vulnerability imply
(Depue & Monroe, 1986; Hammen, 1991; an increased susceptibility to emotional pain
Monroe & Simons, 1991; Rutter, 1986). For and to the occurrence of psychopathology of
instance, a person with social skills deficits some type. Yet, as intuitively straightforward
(e.g., inappropriately critical of others) may as this concept has been, and despite exten-
engender tumultuous relationships with sive discussion in the literature about vulner-
acquaintances, coworkers, and romantic part- ability, few precise definitions are available
ners that result in the generation of significant in the scientific literature. Ingram et al.
stress. Vulnerable individuals, or those in a (1998) noted several core features of vulner-
disordered state, may therefore play a role in ability that appear to constitute the common
creating their own stresses (Ingram et al., themes that emerge in discussions of vulner-
1998). Later in this chapter, we expand on the ability and that can thus help establish a
implications of this idea as it pertains to working definition of the construct. These
diathesis-stress models. ideas suggest that vulnerability is a trait, is
A second factor is the influence of appraisal stable but can change, is endogenous to indi-
processes on what is perceived to be stressful viduals, and is usually latent.
(Monroe, 1989; Monroe & Simons, 1991). Most discussions regard vulnerability as
That is, stress is not independent of the indi- an enduring trait. For example, Zubin and
vidual’s appraisals of events. Even though Spring (1977) argued that “we regard [vul-
there are a number of events that are undoubt- nerability] as a relatively permanent, endur-
edly universally appraised as stressful (e.g., the ing trait” (p. 109). They continue, “The one
death of a loved one), even in these cases indi- feature that all schizophrenics have . . . is the
vidual differences may determine the degree of everpresence of their vulnerability” (p. 122).
stress that is perceived and experienced. In Such assumptions of permanence seem likely
other cases, events that are perceived as stress- to be rooted in the genetic level of analysis
ful by some individuals may be perceived and employed by researchers who pioneered this
experienced as not stressful, or at the least concept, as can be seen among schizophrenia
as minimally stressful, by other individuals. researchers who point to the genetic endow-
Indeed, a multitude of other factors can affect ment of individuals who are at risk for this
the determination and degree of stress. disorder. Meehl’s (1962) idea of schizotaxia
represents an inherited neural deficit,
whereas other researchers, such as Zubin and
Diatheses
Spring, Nicholson and Neufeld (1992), and
We employ the terms diathesis and McGue and Gottesman (1989), explicitly
vulnerability interchangeably. A diathesis, or argue that genetic endowment determines
vulnerability, is typically conceptualized as a one’s level of vulnerability (at least to
predispositional factor, or set of factors, that schizophrenia). Hence, little change is theo-
makes possible a disordered state. The earliest retically possible.
psychopathology models featuring vulnera- Although vulnerability may in many cases
bility suggested that these redispositional be permanent and enduring, this need not
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Vulnerability-Stress Models 35

always be true. For example, when the level or biological factors that may predispose to
of vulnerability analysis is psychological disorder, but it also includes more psycho-
rather than genetic in nature, change may be logically based vulnerability processes.
possible. Even though assumptions of genetic
vulnerability offer little possibility for modi-
Risk and Diatheses/Vulnerability
fication of vulnerability, most psychological
approaches rely on assumptions of dysfunc- Terms such as risk and vulnerability (or
tional learning as the genesis of vulnerability. diatheses) are often used interchangeably, and
Given such assumptions, vulnerability levels in fact there is little doubt that these con-
may fluctuate as a function of new learning structs overlap substantially. However, it is
experiences. important to note that although we use the
The traitlike nature of vulnerability sug- terms diathesis and vulnerability interchange-
gests that vulnerability tends to be, at the ably, we do not view vulnerability and risk as
least, stable. It is important to note, however, interchangeable. As several investigators have
that stability does not necessarily mean per- argued (e.g., Ingram et al., 1998; Luthar &
manence. That is, even though the idea of Zigler, 1991; Rutter, 1987), risk describes
stability suggests a resistance to change, it factors that are associated, or correlated, with
does not presume that change is never possi- an increased likelihood of experiencing a dis-
ble. Under some circumstances, positive order. Nevertheless, the presence of risk sug-
changes in an otherwise stable variable may gests only an increased probability of the
very well occur. Indeed, the notion of ther- occurrence of a disorder; it does not specify
apy is based on just this premise. It is also the what causes the disorder. Risk factors are
case, however, that some experiences (e.g., thus not informative about the actual mecha-
trauma) might serve to strengthen vulnerabil- nisms that bring about a state of psy-
ity. It thus seems reasonable to conceptualize chopathology. For example, female gender is
vulnerability as stable but not immutable. a well-established risk factor for many disor-
Following from the traitlike characteris- ders, but this knowledge alone is uninforma-
tics of vulnerability, another core feature of tive about why women are more likely to
the construct is that vulnerability is an endoge- experience a range of disorders. Alternatively,
nous process. In particular, whether stem- vulnerability is usually defined in such a way
ming from genetically or biologically acquired that it reflects statements about causal mech-
characteristics or acquired through psycho- anisms.1 Risk is certainly an important pre-
logical or learning processes, vulnerability dictive variable that can be seen as acting in
resides within the person. This serves to concert with vulnerability (Rutter, 1988), but
explicitly distinguish vulnerability from these constructs are not synonymous.
“external” stress or life events. Finally,
because diatheses are often not easily recog-
nized, they are frequently considered to be DIATHESIS-STRESS
latent, requiring activation in some fashion ORIGINS CONSIDERED
before psychopathology can occur. Although
not all researchers agree with this position To understand fully diathesis-stress interac-
(e.g., Just, Abramson, & Alloy, 2001), there tions, it is useful to briefly consider the his-
is widespread consensus among many torical context in which these ideas emerged.
researchers concerning the latent nature of Monroe and Simons (1991) note that the
many vulnerability characteristics. This is diathesis concept has a long history in medi-
particularly the case with “unseen” genetic cal terminology. The concept dates back to
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36 OVERVIEW AND FOUNDATIONS

the ancient Greeks; the word diathesis predisposing factors (diatheses) for any given
derives from the ancient Greek idea of dispo- mental disorder. However, individuals have
sition, which is related to the humoral (body their own point at which they will develop
fluids) theory of temperament and disease a given disorder, a point that depends on
(Zuckerman, 1999). By the 1800s, the term the interaction between the degree to which
had become part of the psychiatric language these risk factors exist and the degree of
of the day (e.g., Beard, 1881). Likewise, stress experienced by the individual. Because
although the role of stress had long been con- diathesis-stress models address the interac-
sidered an important factor in the develop- tions between premorbid risk factors and
ment of mental disorders, it was theories situational stressors, they are useful for
of schizophrenia proposed during the 1960s describing who will develop a disorder and
(e.g., Meehl, 1962) that highlighted stress who will not. Many—perhaps most—psy-
and brought the diathesis and stress concepts chopathologists have recognized the concep-
together. More specifically, the particular tual and empirical utility of combining
terminology of the diathesis-stress interac- diathesis and stress constructs, and accord-
tions was developed by Bleuler (1963) and ingly, models of psychopathology tend to be
Rosenthal (1963). explicit diathesis-stress models.
Beyond these pioneering approaches, A variety of diathesis-stress models have
somewhat more contemporary and detailed been proposed for various types of psy-
conceptualizations of the nature of vulnera- chopathology (see Ingram & Price, 2001).
bility and the role of stress have been pro- Depending upon the particular theory, these
posed that specify under what circumstances models suggest specific variables that com-
a disorder will ensue. For example, Audy bine in some fashion to produce the disorder.
(1971) suggested that the preservation of Beyond the description of particular vari-
health requires the maintenance of a dynamic ables in particular disorders, however, these
equilibrium against insults coming from ideas about psychopathology also illustrate
chemical, physical, infectious, psychological, different ways that the structure of a diathesis-
and social environment factors. A disorder stress interaction can be conceptualized.
occurs when the equilibrium is disturbed Examination of these models suggests several
by an inability to maintain homeostasis. general principles that characterize hypothe-
Vulnerability factors influence the ease and sized diathesis-stress interactions.
frequency with which these factors will chal-
lenge homeostasis; such factors therefore
Additivity
determine the probability that the disorder
will occur. Thus, the highly vulnerable per- On the surface, diathesis-stress models
son is one in whom numerous circumstances represent straightforward, linear, dose-
can elicit an episode. response–type relationships, or additive rela-
tionships. Hence, at the most basic level,
many models suggest that whether or not a
GENERAL PRINCIPLES OF disorder will develop depends on the com-
DIATHESIS-STRESS MODELS bined effects of stress and the loading of the
diathesis. One model, for example, may sug-
According to Monroe and Simons (1991) and gest that relatively minor stressors may pre-
Monroe and Hadjiyannakis (2002), most cipitate the onset of the disorder for a person
diathesis-stress models of psychopathology who is highly vulnerable, whereas another
suggest that all people have some level of model might suggest that a major stressful
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Vulnerability-Stress Models 37

event might cause a similar reaction in a needed, but substantial life stress must also
person low in vulnerability. Although vari- occur before the process eventuates in
ous models may accord a stronger role for depression. This differs from an ipsative
one component over the other, this idea pre- model, which suggests that minimal stress is
supposes additivity, that is, the idea that needed for depression to occur in individuals
diatheses and stress add together in some with a strongly depressogenic schema.
way to produce the disorder.
Static Versus Dynamic
Ipsative Models Diathesis-Stress Relationships
Monroe and Hadjiyannakis (2002) note Comparison of ipsative and mega models
that many diathesis-stress models reflect reveals a neglected aspect of many diathesis-
an ipsative approach to the relationship stress models of psychopathology, specifi-
between the constructs. Ipsative models posit cally the idea that the relationship between
an inverse relationship between factors such the diathesis and stress can change over time.
that the greater the presence of one factor, This changing interaction can be illustrated
the less of the other factor is needed to bring by reference to the idea of kindling. In
about the disorder. Ipsative models are not response to data showing that repeated
necessarily distinct from additive approaches episodes of depression within some individu-
and can thus be considered an additional als begin to appear with decreasing stress,
quality of many diathesis-stress models of Post (1992) proposed the idea of kindling.
psychopathology. More specifically, these Kindling suggests that repeated instances of a
models suggest that the diathesis and stress disorder cause neuronal changes that result
sum together to cause psychopathology, and in more sensitivity to stress. With heightened
that whatever this sum is, it reflects an sensitivity, less stress becomes necessary to
inverse relationship. Thus, the degree of activate the requisite processes that lead
effect of diathesis or stress can be offset or to psychopathology. Applying these ideas to
compensated by the other in the summation diathesis-stress models suggests that the pre-
that is needed for psychopathology. cise relationship between these constructs is
not necessarily static. More specifically, this
also suggests that as the relationship changes
Mega Diathesis-Stress Models
with recurrence or relapse, mega processes
Although ipsative (and additive) models may become more ipsative. That is, whereas
are prevalent, Monroe and Hadjiyannakis the mega model suggests that high levels of
(2002) also note that other possibilities exist. both stress and diatheses are needed, the kin-
One such possibility is a model that suggests dling theory suggests that at some point
that disorder results from the combination of diatheses are changed (and presumably
significant life stress and a heightened vul- strengthened) so that less stress becomes nec-
nerability. For the sake of simplicity, we refer essary to activate the vulnerability factors.
to this as a mega diathesis-stress model to Of course, other changes are also possible.
denote that both the diathesis and the stress Recall that we noted that in at least some
must be considerable before a disorder models, diatheses are viewed as stable
occurs. Thus, cognitive models of depression although not necessarily immutable. It is
that conceptually rely on diathesis-stress therefore possible that the relationship
interactions would suggest that not only is between diatheses and stress may change if
the presence of a depressogenic schema the diathesis becomes weaker.
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38 OVERVIEW AND FOUNDATIONS

We believe that consideration of the static High Low

versus dynamic relationship between diatheses High Diathesis Diathesis
(Individual A) (Individual B)
and stress has potentially important implica-
tions for the conceptualization of diathesis-
stress ideas. In general, varying relations Stress
Level
between diatheses and stress models over time
may affect the accuracy of the model at any
given moment, but they may also have con- Low
siderable implications for models that seek to
understand the function of these processes in Not Disorder Present
Present
remission, recovery, relapse, and recurrence.
As we have noted, few contemporary models, Figure 2.1 Additive Model of Diathesis-
at least explicitly, take into theoretical account Stress Interaction With a
potential changes over time of the relationship Dichotomous Diathesis for
between diatheses and stress, but clearly the Disorder
nature of the relationship over time is an
important factor to consider.
schizophrenia, Meehl described the diathesis
as a single dominant “schizogene,” which
DIATHESIS-STRESS MODELS produces a schizotaxic brain pathology (e.g.,
neural integrative defect) that eventuates in a
With the caveat that dynamic relationships schizotypic personality. According to Meehl,
may be quite significant, our focus is on more however, only some people with schizotypic
“static” models of the diathesis-stress pro- personality will develop clinical schizophre-
cesses. At present, most diathesis-stress mod- nia. Most at-risk individuals will not,
els are ipsative, although several permutations because the schizotypic personality, although
are possible. Hence, different investigators necessary for the development of schizophre-
have described these models in somewhat nia, is not sufficient in and of itself for the
varying terms. The models we describe here development of schizophrenia. Instead, an
illustrate these different terms. In particular, environmental stressor is required to produce
we discuss the interactive model with dichoto- schizophrenia. Meehl suggested that the
mous diatheses, the quasi-continuous diathesis stress produced by a schizophrenogenic-type
models, threshold models, and risk-resilience mother who is “ambivalent and inconsis-
continuum models. Before doing so, it is tently aversive to the schizotypic” is the most
important to acknowledge that these models important type of stress that may produce
tend to vary in emphasis rather than in basic the disorder. Alternatively, if the schizogene
structure. Thus, there is considerable overlap is absent, no amount of stress or type of rear-
in how these approaches view the relationship ing will produce schizophrenia. In sum,
between diatheses and stress. Meehl’s theory suggested that the onset of
schizophrenia is a joint function of both
biological and psychological factors.
Interactive Model With
Meehl’s (1962) first model for schizophre-
Dichotomous Diatheses
nia, which arguably launched the idea of
As noted, vulnerability-stress models diatheses and stress, can thus be described
originated from schizophrenia theory and as an interactive model with dichotomous
research, starting with Meehl’s (1962) diatheses (see Figure 2.1). Dichotomous diathe-
groundbreaking ideas. In his first model of sis suggests that one either has the diathesis or
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Vulnerability-Stress Models 39

does not; if the diathesis is absent, there is no High Loading

High
effect for stress. Hence, even severe stress will Diathesis
not lead to the development of the disorder. Present
(Low to High
On the other hand, when the diathesis is pre- Degree of
Loading)
sent, the expression of disorder will be con- Disorder
Minimal Loading
ditional on the degree of stress. That is, as
stress increases, so does the risk for the dis- Low
No Loading
order in those who possess the diathesis.
We note Meehl’s (1962) original model for Low Stress Level High
historical context, but it is also important to
note that this model has been updated to the Figure 2.2 Interactive Model of Diathesis-
extent that it no longer resembles the earlier Stress Interaction With Quasi-
Continuous Diathesis
model. Hence, to better clarify the interac-
tion between diathetic characteristics and
environmental stressors, Meehl (1989, 1990) (2003). They suggest two types of diatheses:
revised his original model to describe another One type consists of ecological variables
pathway that could lead to schizophrenia, and revolves around factors such as child
called the SHAITU genophenocopy (Meehl, abuse and cognitive distortions. Another
1989, 1990). SHAI stands for personality type is biological and includes variables
trait extremes—submissive, hypohedonic, such as neurophysiological dysregulation.
anxious, and introverted—of polygenic ori- Individuals with higher degrees of these
gins, which may increase the potential for premorbid vulnerability factors (diatheses)
schizotaxia to develop into schizotypic per- would not need to experience as severe a
sonality and subsequently lead to clinical stressor to reach the threshold and develop
schizophrenia. TU stands for environmental PTSD symptomatology. In contrast, indi-
risk factors; T stands for major or frequent viduals without the diatheses might not dis-
minor traumas during development, whereas play any signs or symptoms of PTSD even
U stands for unlucky events in adult life, after experiencing a traumatic event. Even
which also increase the risk for schizophrenia. to the extent that signs or symptoms are
In Meehl’s original 1962 model, the domi- experienced, however, they would not be
nant schizogene and the resulting schizotaxic indicative of a clinical disorder.
brain pathology were necessary but not suffi-
cient causes of schizophrenia. In contrast, the
Quasi-Continuous Diathesis Models
SHAITU genophenocopy not only plays a
role in the schizotaxic type of schizophrenia, Dichotomous models suggest that when the
but it can produce a schizophrenic disorder diathesis is absent, there is no effect for stress.
even in the absence of the schizogene. As That is, regardless of the amount of stress expe-
such, however, the revised diathesis-stress rienced by the individual, the disorder will not
model is no longer an example of an occur if the individual does not have the diathe-
interactive model with dichotomous diathesis sis. However, many disorders suggest polygenic
conceptualization. models that allow for varying degrees of diathe-
Although Meehl’s (1962) original model ses (such as the level of a particular neurotrans-
of schizophrenia illustrates the idea of an mitter) (Zuckerman, 1999). Thus, instead of
interactive model with dichotomous diathesis, being dichotomous, the diathesis is “quasi-con-
a more contemporary example can be seen tinuous” (Monroe & Simons, 1991). As illus-
in the posttraumatic stress disorder (PTSD) trated in Figure 2.2, in the quasi-continuous
theory proposed by McKeever and Huff model there is a point beyond which a disorder
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40 OVERVIEW AND FOUNDATIONS

will occur, but there is also a continuous effect Moreover, complex diathesis-stress models
of the diathesis once the threshold is passed. In that represent additive and interactional rela-
other words, a very minimal level of diathesis tionships between variables, as well as
may be insufficient to produce the disorder threshold effects for the diathesis, have also
even under high stress, but the probability of been proposed (Monroe & Simons). These
disorder increases as a function of both level of ideas can be illustrated by what we would
stress and strength of the diathesis beyond a term a threshold model.
minimal level (Zuckerman). To illustrate a threshold model, consider
Few models of psychopathology are explic- the integrative model of schizophrenia
itly framed in terms of a continuous or quasi- proposed by Zubin and Spring (1977).
continuous vulnerability model, but it is easy Zubin and Spring suggest that every person
to see how this diathesis-stress conceptualization has a degree of vulnerability that represents a
could be applied to psychopathology models. threshold for the development of schizophre-
Moreover, this idea could also help clarify or nia. At the most basic level, this model sug-
refine these models. For example, schema gests that as the intensity of the trauma
models of depression are typically conceptu- (stressor) increases, so too do the risks for
ally stated as dichotomous models; if the indi- psychopathology. The diathetic threshold is
vidual possesses a depressogenic schema, then the point at which the people who fall below
he or she is at risk for depression when events the threshold will not develop the disorder,
occur that activate this schema (see Beck, whereas those above this level cross the
1967, for the original description of the role threshold into disorder (see Bebbington,
of depressogenic schemata in depression). 1987; Monroe & Simons, 1991). Thus, the
However, various discussions of the proper- threshold for triggering schizophrenia may
ties of schemata suggest how schemata could vary from one person to the next depending
be conceptualized in more continuous terms on the degree of vulnerability and the level of
(e.g., the relative density and strength of nega- stress experienced. For a person who is
tive connections; see Segal, 1988). Some highly vulnerable, relatively minor stressors
descriptions of these processes have been may cause the threshold to be crossed. On
implicitly, but rarely explicitly, suggested (see the other hand, a major stressful event might
Ingram et al., 1998). To the extent that cause a similar reaction even for a person low
schemata could explicitly be considered to in vulnerability.
represent a more continuous variable, such
that some individuals may possess schemata
Risk-Resilience Continuum Models
that are “strongly” depressogenic, whereas
others may possess only “weak” or mild Invulnerability, competence, protective
depressive schemata, then a more continuous factors, and resilience are terms often used
diathesis-stress model may not only be appli- to describe the opposite of vulnerability
cable to depression, but may also suggest (Ingram & Price, 2001). Resilience can be
refinement of key elements of the theory that thought of as factors that make a person
were not previously considered. resistant to the deleterious effects of stres-
sors. Examples of resilience features could
include particular personality traits, social
Threshold Models
skills, and coping responses. Resilience and
Some models suggest that the synergism vulnerability represent, therefore, opposite
between the diathesis and stress yields an ends of a vulnerability continuum, although
effect beyond their combined separate effects models typically do not specify if resilience
(Monroe & Simons, 1991; Rothman, 1976). simply reflects the lack of vulnerability
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Vulnerability-Stress Models 41

Extreme Mild experience stress and who are vulnerable. On

Severe Disorder the other hand, highly vulnerable people who
encounter significant stress are proposed to
Threshold
experience a more severely disordered state.
Stress
Mild
This model therefore takes into account not
Disorder only the continuum of vulnerability, ranging
from vulnerable to resilient, but also a contin-
Low uum of disorder severity.
Vulnerable Resilient
Vulnerability
Continuum
SOME ISSUES FOR CONSIDERATION
Figure 2.3 The Vulnerability-Resilience IN DIATHESIS-STRESS MODELS
Model
While maintaining the same basic structure,
factors or instead encompasses specific the models we have described reflect the
factors that confer resilience. different approaches that investigators have
As in other models, the diathesis contin- taken to understanding psychopathology.
uum interacts with a continuum of stress to Beyond these basic models, there are, however,
produce the possibility that a disordered state a number of issues that need to be considered
will occur. At the most extreme vulnerability as efforts continue to more fully understand
end of the spectrum, little life stress is neces- how diatheses and stress interact to produce
sary to trigger disorder. At the resilient end, psychopathology. Although artificial in some
however, a great deal of stress is needed before respects, for discussion purposes we divide
psychopathology develops. A vulnerability- these into diathesis issues and stress issues.
resilience relationship is presented in Figure
2.3. As this figure illustrates, with decreasing
Diathesis Issues in Diathesis-
resilience, and hence increasing vulnerability,
Stress Models: Single Versus
the probability that stress will result in a dis-
Multiple Diatheses Factors
order increases. Conversely, when resilience
increases, the risk of disorder goes down but For models suggesting genetic diatheses,
does not vanish entirely. That is, resilience evidence of the polygenic aspect of psy-
may be the opposite of vulnerability, suggest- chopathological disorders suggests a combina-
ing a resistance to disorder but not immunity tion of genes that may be required for
from it entirely (Ingram et al., 1998). Of disorder. Thus, individuals inheriting any par-
course, although not specified by most mod- ticular gene defect will be normal if they do
els, the idea of resilience can easily be incor- not possess the other gene defects needed to
porated into diathesis-stress interactions. produce a disorder such as schizophrenia. Of
Like a threshold model, a risk-resilience course, genetic diatheses are not the only
model also notes a threshold at which a approach to understanding psychopathology.
particular disorder will be encountered. Hence, models featuring psychosocial factors
However, this model can also take into may also need to highlight more than one dia-
account the severity of psychopathology that thetic factor. For example, an interpersonal
is experienced. Hence, even the most resilient and cognitive model of depression (Gotlib &
people can be at risk for developing significant Hammen, 1992) extended to vulnerability
symptomatology with enough stress, although would need to specify the multiple diathesis
the symptomatology will likely be less severe factors that fall into their respective cognitive
than that experienced by individuals who and interpersonal categories, and the link
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42 OVERVIEW AND FOUNDATIONS

between them, to provide a more complete example, it may be that likelihood of incurring
model. Likewise, models that highlight biolog- a stressor increases with the loading of the
ical and psychological factors (e.g., Goodman diathesis. To the extent that the diathesis
& Gotlib, 1999) would also need to specify influences the incidence of the requisite forms
the link between various processes and how of stress, the more likely it is that highly
they would work in concert to produce the predisposed people will develop a disorder.
disorder when life stress is encountered. For a young person in the early stages of
schizophrenia onset, for example, abnormal
or socially withdrawn behavior that results
Development and Stress Issues
from diathesis may create tension in the
in Diathesis-Stress Models
young person’s interpersonal life at home
The nature of the diathesis-stress interaction and at school. The additional interpersonal
described in various models is often ambiguous stress, which is directly influenced by the
(Monroe & Hadjiyannakis, 2002). As we have diathesis, may exacerbate stress and subse-
noted in our description of schema models of quently increase the likelihood of the onset of
depression, diatheses are often portrayed as full-blown schizophrenia.
discontinuous and categorical (people either This idea is similar to proposals regarding
have a given diathesis or they do not). stress generation. As we have previously
Alternatively, stress is frequently portrayed noted, stress is typically seen as operating
as nonspecific and continuous, varying only externally to the individual, although it does
in degree but not in type. However, diatheses appear that at least some people may also play
can often become continuous once a certain a part in creating the stressful environment
threshold has been reached. Moreover, that acts to trigger pathology. That is, the
because diatheses and stress are rarely com- diathesis may influence the manner in which a
pletely independent of each other, the inter- person deals with life and thus the nature of
actions between the diathesis and stress can the stressors to which he or she is exposed.
be quite complex (Monroe & Simons, 1991). Indeed, a number of researchers have argued
Early formulations of the diathesis-stress that many stressors may constitute the results
model were based on biological factors (e.g., of one’s own actions (Depue & Monroe,
Meehl, 1962) that inferred temporal prece- 1986; Hammen, 1991, 1992; Monroe &
dence and assumed that the diathesis was Simons, 1991; Rutter, 1986). For example,
inactive in the developmental scheme of people who have doubts about their self-
things. Thus, the interpretation of a signifi- worth may seek reassurance in an effort to
cant interaction seemed relatively clear-cut: counter these doubts (Luxton & Wenzlaff, in
Stress activated the diathesis, which in turn press), but repeated efforts may result in rejec-
brought about the onset of disorder. This tion from others, therefore precipitating a
interpretation suggests that until the diathe- depressive disorder. Beyond the exacerbation
sis is activated by stress, the diathesis is of stress that may occur as the result of the
inconsequential. The complementary influ- emergent activation of diatheses, vulnerable
ence of the diathesis on stress was typically individuals may thus play a role in creating
disregarded in these early models (Monroe their own stresses, which may then activate
& Simons, 1991). the diatheses and precipitate disorder.
The influence of diatheses on stress also Some models have proposed that the vul-
received little attention in early formulations nerability factor itself affects the perception
of this relationship, but there are several of stress (e.g., Zubin & Spring, 1977), sug-
ways in which the constructs may not be as gesting that stress is not independent from
independent as they seem at first glance. For vulnerability. In this sense, the vulnerability
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Vulnerability-Stress Models 43

does not “cause” the stress in this case, but and ineffective coping competencies may
rather the vulnerability is part of the stress. contribute to the occurrence of stressful
In other cases, stress may affect the devel- events and circumstances—and these in turn
opment of the diathesis. For example, there may trigger depressive reactions.
is evidence to suggest that stress may play a
role in the etiology of schizophrenia as early
as the prenatal period, when the fetus is SUMMARY AND CONCLUSIONS
exposed to a possible range of developmen-
tal insults that in turn produces the diathe- Individually, vulnerability and stress are
sis (Brennan & Walker, 2001). In depression important concepts, but their real power lies
theory and research, the “scar” hypothesis in their interaction. Diathesis-stress models
(Rohde, Lewinsohn, & Seeley, 1990) sug- thus describe the interactions between these
gests that a first episode of depression may constructs and are useful for understanding
leave cognitive scars in the form of negative the development of psychopathology. In this
thinking patterns that may not have been chapter, we described some basic principles
previously present. If such scars subse- that characterize diatheses-stress models, such
quently serve as a diathesis for additional as the idea that models tend to be additive and
episodes of depression, then this may be ipsative. We also noted that mega diathesis-
understood as a stress-induced diathesis. stress models are also possible, although
Not only may a disorder be the result of uncommon, and emphasized the importance
both diathesis and stress, but the diatheses of considering varying relationships between
may precipitate stress that combines with diatheses and stress over time. We also
stress not related to the diatheses (Monroe & described the interactive model with dichoto-
Simons, 1991). For example, “external” stres- mous diatheses approach to diathesis-stress
sors (e.g., a death in the family, alcoholic conceptualizations, the quasi-continuous
parent, socioeconomic strife) may or may not diathesis model, threshold models, and risk-
be substantial enough to trigger the disorder. resilience continuum models. In describing
However, if the diathesis plays a direct role in these different models, however, we also
creating “other” kinds of stress by, for noted that these models tend to vary not in
example, increasing tension in the person’s basic structure but rater in the emphasis that
interpersonal life, the combined state of affairs different investigators give to different com-
may subsequently increase the likelihood of ponents. Finally, within the context of diathe-
the onset of a full-blown disorder. sis-stress interactions, we noted some
Typically, diathesis-stress models refer to outstanding issues that reflect on conceptual-
stressful events that are proximal to the onset izations of diatheses and conceptualizations
of disorder. However, it should be noted that of stress.
stressors earlier in life may also influence how The development of psychopathology is
later stressful events are responded to and obviously complex and involves numerous
thus increase future susceptibility to disorder. vulnerability factors and interactions between
For example, maladaptive methods of coping those factors and stress. Diathesis-stress mod-
with stress in childhood and throughout els are excellent heuristic devices (Monroe &
development may be detrimental to the devel- Simons, 1991) that enable us to potentially
opment of effective coping competencies; understand how predispositional factors from
lacking effective coping skills, in turn, can various domains may increase susceptibility
compromise resilience and encourage vul- to psychopathology and subsequently create
nerability (Hammen, 1992). Thus, maladap- the sufficient conditions for the onset of
tive cognitions about the self and others disorder. Furthermore, diathesis-stress models
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44 OVERVIEW AND FOUNDATIONS

help describe how diatheses and stressors can be able to understand the multifactoral
be better conceptualized and more precisely complexity of psychopathology, including
measured empirically with respect to specific developmental experiences, biological vulnera-
forms of psychopathology. Such models are bilities, psychological susceptibilities, and
necessary if psychopathologists ever hope to socioenvironmental variables.

NOTE

1. Because possessing vulnerability places one at higher risk for developing a

disorder, vulnerability is probably most accurately seen as a subcategory of risk.

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